Subjective: Chief complaint: headaches and blurriness of vision on the right side History of present illness: the patient is 67 years old Caucasian female, she complains of having had headaches for 2 weeks now. The pain is located in the right temporal area. She describes the pain as 8-10/10, sharp, constant, interferes with her sleep, she states that nothing aggravates it, not even the bright lights or high sounds, but she gets a little relief by taking Ibuprofen 800 mg. She stated that she has been having some blurriness in the right eye, while her left eye is fine. She also complains of pain in her jaw and tongue while chewing food. Her appetite has been low, and lost about 5 pounds in the last 2 weeks. She noticed low grade fever as well. She also reported ringing sounds in the right ear. She denies any nausea or vomiting. She denied having similar headaches in the past. The patient denies complaining of nasal or postnasal drainage. PMH: past medical history is significant for Hypertension, type II diabetes mellitus, asthma, and degenerative arthritis of the knees. PSH: hysterectomy Medications: Lisinopril 10 mg PO QD Metformin 500 mg PO BID. Proair HFA 2 puffs PRN. Ibuprofen 800 mg TID Multivitamins By comparing the medications that the patient is taking with Beers criteria, they all looked appropriate to be used in elderly patients. Family Hx: Father: HTN, diabetes, and stroke. Mother: HTN, Diabetes, and breast cancer at the age of 72. Social Hx: the patient never smoked tobacco products. ETOH: social drinker Illicit substances: denies ever using illicit drugs. Allergies: penicillin. Review of systems: Constitutional: the patient complains of fever, fatigue, anorexia, and weight loss. Head: the patient denies complaining dizziness or lightheadedness. Eyes: blurriness in the right eye. Ears: the patient reports tinnitus- right ear, but denies complaining of ear pain or ear discharge Nose: the patient denies any nasal bleeding, discharge or obstruction Mouth: the patient reports painful chewing, she denies gingival bleeding, having mouth sores, or having dental difficulties Throat: no sore throat Cardiovascular: the patient denies complaining of Chest pain, palpitations, or swelling in the legs. Respiratory: the patient denies any wheezing, shortness of breath or coughing. Gastrointestinal: the patient denies any nausea, vomiting, GERD, epigastric pain, diarrhea, constipation, having black stools, or blood in stool. Genitourinary: the patient denies any dysuria, polyuria, or visible hematuria Musculoskeletal: bilateral knee pain. Integumentary (Skin): the patient denies having any skin rash or skin discolorations. Neurological: the patient denies complaining of tingling or numbness in any extremity; there is no history of seizures, stroke, syncope, or memory changes. Psychiatric: the patient denies complaining of depression, or anxiety, denies complaining of hallucinations. Endocrine: the pat ...

1. Subjective:
Chief complaint: headaches and blurriness of vision on the right
side
History of present illness: the patient is 67 years old Caucasian
female, she complains of having had headaches for 2 weeks
now. The pain is located in the right temporal area. She
describes the pain as 8-10/10, sharp, constant, interferes with
her sleep, she states that nothing aggravates it, not even the
bright lights or high sounds, but she gets a little relief by taking
Ibuprofen 800 mg. She stated that she has been having some
blurriness in the right eye, while her left eye is fine. She also
complains of pain in her jaw and tongue while chewing food.
Her appetite has been low, and lost about 5 pounds in the last 2
weeks. She noticed low grade fever as well. She also reported
ringing sounds in the right ear. She denies any nausea or
vomiting. She denied having similar headaches in the past. The
patient denies complaining of nasal or postnasal drainage.
PMH: past medical history is significant for Hypertension, type
II diabetes mellitus, asthma, and degenerative arthritis of the
knees.
PSH: hysterectomy
Medications: Lisinopril 10 mg PO QD
Metformin 500 mg PO BID.
Proair HFA 2 puffs PRN.
Ibuprofen 800 mg TID

2. Multivitamins
By comparing the medications that the patient is taking with
Beers criteria, they all looked appropriate to be used in elderly
patients.
Family Hx:
Father: HTN, diabetes, and stroke.
Mother: HTN, Diabetes, and breast cancer at the age of 72.
Social Hx: the patient never smoked tobacco products.
ETOH: social drinker
Illicit substances: denies ever using illicit drugs.
Allergies: penicillin.
Review of systems:
Constitutional: the patient complains of fever, fatigue,
anorexia, and weight loss.
Head: the patient denies complaining dizziness or
lightheadedness.
Eyes: blurriness in the right eye.
Ears: the patient reports tinnitus- right ear, but denies
complaining of ear pain or ear discharge
Nose: the patient denies any nasal bleeding, discharge or
obstruction

3. Mouth: the patient reports painful chewing, she denies gingival
bleeding, having mouth sores, or having dental difficulties
Throat: no sore throat
Cardiovascular: the patient denies complaining of Chest pain,
palpitations, or swelling in the legs.
Respiratory: the patient denies any wheezing, shortness of
breath or coughing.
Gastrointestinal: the patient denies any nausea, vomiting,
GERD, epigastric pain, diarrhea, constipation, having black
stools, or blood in stool.
Genitourinary: the patient denies any dysuria, polyuria, or
visible hematuria
Musculoskeletal: bilateral knee pain.
Integumentary (Skin): the patient denies having any skin rash or
skin discolorations.
Neurological: the patient denies complaining of tingling or
numbness in any extremity; there is no history of seizures,
stroke, syncope, or memory changes.
Psychiatric: the patient denies complaining of depression, or
anxiety, denies complaining of hallucinations.
Endocrine: the patient denies any cold or heat intolerance, no
polyuria
Hematologic/Lymphatic: the patient denies noticing swollen
glands in the neck, armpits, or the groin area. She denies easy

4. bruising.
Allergic/Immunologic: no environmental allergens.
OBJECTIVE:
Vital Signs
Height: 63.00 in
Weight: 191.20 lbs
BMI: 33.87
Blood Pressure: 121/81 mmHg
B/P Side: Left
B/P Position: Sitting
Temperature: 97.40 F
Pulse: 73 beats/min
Resp. Rate: 15
Physical Exam:
The neurological exam: tenderness in the right temporal area.
The patient is alert and orientated to time/place/self-cranial
nerves II-XII intact DTRs 2+/4 in the upper and lower
extremities. The muscle strength is 5/5 in all 4 extremities.
Cardiovascular: Palpation of the head reveals prominent right
temporal artery with weak pulsation, and bruit on auscultation.
No JVD was noticed. The heart auscultation: normal S1, and S2,

5. no murmurs, or rubs.
Constitutional: the patient is well groomed, alert and oriented x
3. pt responds appropriate to questions
Eyes ,ears, Nose, Mouth, and Throat: the funduscopic
examination showed a swollen pale right disc, while the left
one was normal. EOMI: the extraocular eye movements are
intact, but the patient reported double visions when she looked
to the right side upon doing the finger tracking, the visual
acuity using Snellen chart is 20/50 for the right eye and 20/25
for the left eye. The oropharynx is well hydrated, there is no
exudates or plaques, the mucous membranes are moist, not
erythematous, there are no ulcerations, there are no tongue
plaques, no cyanosis, there is no facial droop, the swallowing
intact, CNs II-XII grossly intact PEERLA: pupil equal, round,
reactive to light and accommodation.
Neck: no lymphadenopathy, no thyromegaly. The cervical
spine: there are no tender points, FROM
Respiratory: the patient is not tachypneic, dyspneic, no clubbed
fingers were noted, the Lung: no wheezing, crackles, or ralls.
Lymphatic: no palpable lymph nodes in the cervical, axillary or
the inguinal areas.
Extremities: I noticed +2 pitting edema extending from the
knees to the feet. The peripheral pulse is strong +2 and regular.
The functional assessment was performed too: when the patient
was asked about eating, dressing, bathing, transferring between
the bed and a chair, using the toilet, controlling bladder and
bowel functions, doing housework, preparing meals, taking
medications properly, managing finances, using a telephone; she
stated that she can perform all these tasks without the needing

6. help. During the examination, the patient was noticed to be able
to unbutton and then button up her jacket, take off, and put on
her shoes, and climbing up and down the examination table
without the help.
ASSESSMENT:
Primary diagnosis: Temporal arteritis
Differential diagnosis: .
1. Glaucoma
2. Migraine headaches
3. Acute paranasal sinusitis
4. Polymyalgia rheumatica
5. Brain tumor
6. Granulomatosis with Polyangiitis (Wegener Granulomatosis)
7. Iritis and Uveitis
8. Persistent Idiopathic Facial Pain
9. Retinal Artery Occlusion
10. Retinal Vein Occlusion
Care Plan: CBC, CMP, ESR, and C-reactive protein.
Biopsy of the Carotid artery
Carotid Doppler

7. Evaluating the patient by an ophthalmologist for Tonometry and
evaluation for glaucoma.
Treatment plan: Methylprednisolone 1 gram IV for 3 days,
followed by 40-60 mg Prednisone orally, and then starts
tapering.
The alternative therapy includes Methotrexate if the patient
developed severe side effects to steroids.
And as a caregiver I explained to the patient how important it
was to start her on high dosage of steroids, to prevent her from
getting blind, and how important was it to get a carotid biopsy,
especially after she showed concern about her getting a cut in a
major neck vessel.
Reflection notes:
1. If there was no visual involvement I would put the patient on
40-66 mg oral prednisone.
2. I would order Head CT scan or MRI if the patient had focal
neurological findings.
3. Head X ray if there was nasal or postnasal drainage.
For me I understood how serious headache could be. And it was
clear to me how taking a thorough history, and physical exam
helps in determining what diagnostic tests are needed. And with
the collaboration of physicians in different fields of practice we
can reach the final diagnosis and helping patient from getting
severe irreversible complications.
Making a concise and accessible report will help other
professionals to care for the patient effectively even if some of
the symptoms are no longer present. It would be beneficial to
facilitate clear channel relationships with the other
professionals or teams that will be involved in caring for the
patient and avoid the stereotypes that are commonly held about
other health care professions involved. Furthermore, to improve

8. interprofessional collaboration, as part of patient report update,
I could utilize visual layouts to convey some of my findings and
try to communicate in necessary ways to different groups within
a team (Ross, King & Firth, 2005)
Referenece
Ross, A., King, N., & Firth, J. (2005). Interprofessional
relationships and collaborative working: encouraging reflective
practice. Online Journal of issues in Nursing, 10(1).
© 2012 Laureate Education Inc.
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